eMedicine Specialties > Ophthalmology > Neurologic Disorders

Bell Palsy: Differential Diagnoses & Workup

Author: Thomas R Hedges III, MD, Director of Neuro-Ophthalmology, New England Eye Center; Professor, Departments of Neurology and Ophthalmology, Tufts University School of Medicine
Contributor Information and Disclosures

Updated: Oct 30, 2009

Differential Diagnoses

Herpes Simplex
Ocular Manifestations of Syphilis
Herpes Zoster
Sarcoidosis
HIV
Lyme Disease
Myasthenia Gravis

Other Problems to Be Considered

Facial nerve schwannoma
Leukemia/lymphoma
Mycoplasma
Nasopharyngeal carcinoma
Parotid gland tumor
Geniculate ganglion infection
Pontine lesions
Cerebellopontine angle disorders
Otitis media
Parotid gland disease
Congenital malformation
Melkersson-Rosenthal syndrome
Guillain-Barré syndrome
Trauma

Workup

Laboratory Studies

  • No specific diagnostic tests are available for Bell palsy.
  • In consideration of the differential diagnosis, the following tests may be beneficial:
    • Determination of the Lyme titer
    • Rapid plasma reagin (RPR) and/or venereal disease research laboratory (VDRL) test or fluorescent treponemal antibody absorption (FTA-ABS) test
    • HIV screening by means of enzyme-linked immunosorbent assay (ELISA) and/or Western blot
    • CBC determination
    • Determination of the erythrocyte sedimentation rate

Imaging Studies

  • Perform gadolinium-enhanced MRI when findings are atypical or when the facial-nerve paralysis appears central to rule out a tumor or vascular compression.12

Other Tests

  • Perform careful clinical examination to evaluate for possible causes of facial paralysis.
    • Bell palsy rarely occurs with other cranial-nerve palsies or brainstem signs.
    • In children, facial palsy may be caused by pontine glioma, whereas in young and middle-aged adults, facial palsy can be an early sign of a cerebellopontine tumor.13
  • Time must also be taken to examine the patient's skin for signs of squamous cell carcinoma, which can invade the facial nerve, and parotid gland disease.

Procedures

  • Possible facial-nerve EMG
  • Lumbar puncture with analysis

More on Bell Palsy

Overview: Bell Palsy
Differential Diagnoses & Workup: Bell Palsy
Treatment & Medication: Bell Palsy
Follow-up: Bell Palsy
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Peitersen E. The natural history of Bell's palsy. Am J Otol. Oct 1982;4(2):107-11. [Medline].

  2. Hashisaki GT. Medical management of Bell's palsy. Compr Ther. Nov 1997;23(11):715-8. [Medline].

  3. Adour KK, Byl FM, Hilsinger RL Jr, Kahn ZM, Sheldon MI. The true nature of Bell's palsy: analysis of 1,000 consecutive patients. Laryngoscope. May 1978;88(5):787-801. [Medline].

  4. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med. Oct 18 2007;357(16):1598-607. [Medline].

  5. Engström M, Berg T, Stjernquist-Desatnik A, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. Nov 2008;7(11):993-1000. [Medline].

  6. Halperin JJ, Golightly M. Lyme borreliosis in Bell's palsy. Long Island Neuroborreliosis Collaborative Study Group. Neurology. Jul 1992;42(7):1268-70. [Medline].

  7. Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4-30. [Medline].

  8. Vrabec JT, Backous DD, Djalilian HR, Gidley PW, Leonetti JP, Marzo SJ. Facial Nerve Grading System 2.0. Otolaryngol Head Neck Surg. Apr 2009;140(4):445-50. [Medline].

  9. Liu J, Li Y, Yuan X, Lin Z. Bell's palsy may have relations to bacterial infection. Med Hypotheses. Feb 2009;72(2):169-70. [Medline].

  10. Gordon SC. Bell's palsy in children: role of the school nurse in early recognition and referral. J Sch Nurs. Dec 2008;24(6):398-406. [Medline].

  11. Seiff SR, Chang J. Management of ophthalmic complications of facial nerve palsy. Otolaryngol Clin North Am. Jun 1992;25(3):669-90. [Medline].

  12. Murphy TP. MRI of the facial nerve during paralysis. Otolaryngol Head Neck Surg. Jan 1991;104(1):47-51. [Medline].

  13. Gilden DH. Clinical practice. Bell's Palsy. N Engl J Med. Sep 23 2004;351(13):1323-31. [Medline].

  14. [Best Evidence] Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ. 2009;339:b3354. [Medline].

  15. Holland NJ, Weiner GM. Recent developments in Bell's palsy. BMJ. Sep 4 2004;329(7465):553-7. [Medline].

  16. Julian GG, Hoffmann JF, Shelton C. Surgical rehabilitation of facial nerve paralysis. Otolaryngol Clin North Am. Oct 1997;30(5):701-26. [Medline].

  17. Olver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol. Dec 2000;84(12):1401-6. [Medline].

  18. Gilden D. Treatment of Bell's palsy--the pendulum has swung back to steroids alone. Lancet Neurol. Nov 2008;7(11):976-7. [Medline].

  19. Engstrom M, Berg T, Stjernquist-Desatnik A, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol. Nov 2008;7(11):993-1000. [Medline].

  20. Sathirapanya P, Sathirapanya C. Clinical prognostic factors for treatment outcome in Bell's palsy: a prospective study. J Med Assoc Thai. Aug 2008;91(8):1182-8. [Medline].

  21. Bauer CA, Coker NJ. Update on facial nerve disorders. Otolaryngol Clin North Am. Jun 1996;29(3):445-54. [Medline].

  22. Chua CN, Quhill F, Jones E, Voon LW, Ahad M, Rowson N. Treatment of aberrant facial nerve regeneration with botulinum toxin A. Orbit. Dec 2004;23(4):213-8. [Medline].

  23. Davies R. Facial nerve palsy. In: Levine M, ed. Manual of Oculoplastic Surgery. 2003. Butterworth-Heinemann: Boston, MA; 197-202.

  24. English JB, Stommel EW, Bernat JL. Recurrent Bell's palsy. Neurology. Aug 1996;47(2):604-5. [Medline].

  25. Grogan PM, Gronseth GS. Practice parameter: Steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Apr 10 2001;56(7):830-6. [Medline].

  26. Jackson CG, von Doersten PG. The facial nerve. Current trends in diagnosis, treatment, and rehabilitation. Med Clin North Am. Jan 1999;83(1):179-95, x. [Medline].

  27. Lee V, Currie Z, Collin JR. Ophthalmic management of facial nerve palsy. Eye. Dec 2004;18(12):1225-34. [Medline].

  28. Williamson IG, Whelan TR. The clinical problem of Bell's palsy: is treatment with steroids effective?. Br J Gen Pract. Dec 1996;46(413):743-7. [Medline].

[ CLOSE WINDOW ]

Keywords

Bell palsy, Bell's palsy, facial nerve paralysis, idiopathic facial palsy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Thomas R Hedges III, MD, Director of Neuro-Ophthalmology, New England Eye Center; Professor, Departments of Neurology and Ophthalmology, Tufts University School of Medicine
Thomas R Hedges III, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.